REFUSE (REFusal of discharge Under Specialist Encounter): A qualitative study

Abstract Introduction In Singapore, the rising prevalence of multi-morbidity among a rapidly aging population has led to an exponential increase in demand for cardiology specialist clinic services. Healthcare workers (HCW) frequently encounter patients who refuse discharge from the cardiology clinic to primary care, further exacerbating the workload. This hospital-based, physician-centric model of care is not sustainable. Hence, it is propitious to explore HCW’s perspectives of and experiences with patients who refuse discharge. Aims We aim to explore HCW’s perspectives of and experiences with patients who refuse to be discharged from the cardiology clinic, and the resulting impact on clinical services. Methods The study used a descriptive qualitative design. Doctors, nurses, patient service associates and medical social workers who worked in the cardiology clinic were invited to participate in individual, semi-structured interviews from January 2023 to March 2023. Participant recruitment concluded upon data saturation. In total, 15 participants were recruited with an even distribution among the different occupations. The duration of interviews ranged from 21 to 39 minutes.. A thematic analysis was conducted. Findings Table 1 depicts the findings of the study. Three main themes emerged: 1) Convenient and reliable "one-stop shop" 2) Scale of problem and consequences of patients’ refusal to be discharged 3) Facilitating the shift from patient refusal to acceptance. Each theme was further supported by two subthemes. Interestingly, there was a marked difference in perspectives between doctors and patient service associates with regards to the severity of the problem. Conclusion Patients’ refusal to be discharge stems from the deep trust patients have with HCWs in the cardiology clinic. Comprehensive handover of cases to primary care and seamless access back to cardiology clinic are needed to facilitate patient discharge. This ensures right-siting of care, ensuring specialist services are reserved for patients requiring higher acuity of care.For image description, please refer to the figure legend and surrounding text.